Individual
CHRISTINA TAN MICHELLE KENNEDY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
O.D.
Contact information
Practice address
6709 W JEFFERSON BLVD, FORT WAYNE, IN 46804-6209
(260) 432-8409
(260) 484-0616
Mailing address
3060 FRANKLIN TER, JOHNSON CITY, TN 37604-4123
(423) 282-4221
(423) 282-5124
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
18003936AB
IN
152W00000X
Optometrist
2916
TN
152W00000X
Optometrist
4901004315
MI
152W00000X
Optometrist
OPT002409
GA
Other
Enumeration date
12/07/2006
Last updated
05/03/2019
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